Delivery system attachment

ABSTRACT

A covering for delivering a substance or material to a surgical site is provided. The covering, with substance provided therein, may be referred to as a delivery system. Generally, the covering may be a single or multi-compartment structure capable of at least partially retaining a substance provided therein until the covering is placed at a surgical site. Upon placement, the covering may facilitate transfer of the substance or surrounding materials. For example, the substance may be released (actively or passively) to the surgical site. The covering may participate in, control, or otherwise adjust, the release of the substance.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. application Ser. No.12/171,168 filed Jul. 10, 2008 and claims benefit of priority to U.S.Provisional Application No. 60/948,866 filed Jul. 10, 2007; U.S.Provisional Application No. 61/040,531 filed Mar. 28, 2008, U.S.Provisional Application No. 61/040,537 filed Mar. 28, 2008, and U.S.application Ser. No. 12/171,125, filed Jul. 10, 2008, the contents ofall of which are hereby incorporated in their entirety by reference.

FIELD

A delivery system for delivering a substance or material to a surgicalsite is provided. More particularly, a delivery system comprising acovering and a substance, the covering being configured for at leastpartially retaining the substance provided therein until the deliverysystem is placed at a surgical site, and thereafter facilitatingtransfer of the substance or surrounding materials, is provided.

BACKGROUND

The use of bone grafts and bone substitute materials in orthopedicmedicine is known. While bone wounds can regenerate without theformation of scar tissue, fractures and other orthopedic injuries take along time to heal, during which time the bone is unable to supportphysiologic loading unaided. Metal pins, screws, rods, plates and meshesare frequently required to replace the mechanical functions of injuredbone. However, metal is significantly more stiff than bone. Use of metalimplants may result in decreased bone density around the implant sitedue to stress shielding. Physiologic stresses and corrosion may causemetal implants to fracture. Unlike bone, which can heal small damagecracks through remodeling to prevent more extensive damage and failure,damaged metal implants can only be replaced or removed. The naturalcellular healing and remodeling mechanisms of the body coordinateremoval of bone and bone grafts by osteoclast cells and formation ofbone by osteoblast cells.

Conventionally, bone tissue regeneration is achieved by filling a bonerepair site with a bone graft. Over time, the bone graft is incorporatedby the host and new bone remodels the bone graft. In order to place thebone graft, it is common to use a monolithic bone graft or to form anosteoimplant comprising particulated bone in a carrier. The carrier isthus chosen to be biocompatible, to be resorbable, and to have releasecharacteristics such that the bone graft is accessible. Generally, theformed implant, whether monolithic or particulated and in a carrier, issubstantially solid at the time of implantation and thus does notconform to the implant site. Further, the implant is substantiallycomplete at the time of implantation and thus provides little abilityfor customization, for example by the addition of autograft.

The use of bone grafts is generally limited by the available shape andsize of grafts. Bone grafts using cortical bone remodel slowly becauseof their limited porosity. Traditional bone substitute materials andbone chips are more quickly remodeled but cannot immediately providemechanical support. In addition, while bone substitute materials andbone chips can be used to fill oddly shaped bone defects, such materialsare not as well suited for wrapping or resurfacing bone.

Thus, it would be useful to provide a delivery system for delivering asubstance, such as bone graft, to a surgical site that conforms to thesurgical site, that maintains a substance provided therein in a coherentmass, and that can be customized at the time of implantation.

SUMMARY

A delivery system for delivering a substance or material to a surgicalsite is provided. The delivery system comprises a covering and asubstance to be retained within and delivered by the covering.Generally, the covering may be a single or multi-compartment structurecapable of at least partially retaining a substance provided thereinuntil the covering is placed at a surgical site. Upon placement, thecovering facilitates transfer of the substance and/or materialssurrounding the surgical site. The covering may participate in, control,or otherwise adjust, the release of the substance or penetration of thecovering by surrounding materials, such as cells or tissues.

In accordance with one embodiment, a delivery system is providedcomprising a covering having a first compartment and an attachmentmechanism. A substance is provided in the first compartment. In someembodiments, the covering may comprise a second compartment with a firstsubstance provided in the first compartment and a second substance(which may be the first substance, another substance, or combinations ofthese) provided in the second compartment. The covering retains thefirst and/or second substances for placement at a surgical site andfacilitates transfer of the first and second substances or surroundingmaterials, actively or passively, upon implantation. The attachmentmechanism may be a mechanical attachment mechanism, a physicalattachment mechanism, or a chemical attachment mechanism. In someembodiments, combinations of attachment mechanisms may be used.

While multiple embodiments are disclosed, still other embodiments of thepresent invention will become apparent to those skilled in the art fromthe following detailed description. As will be apparent, the inventionis capable of modifications in various obvious aspects, all withoutdeparting from the spirit and scope of the present invention.Accordingly, the detailed description is to be regarded as illustrativein nature and not restrictive.

BRIEF DESCRIPTION

FIG. 1 a illustrates a delivery system comprising a relatively narrowtubular covering and a particulated substance, in accordance with oneembodiment.

FIG. 1 b illustrates an alternative view of the delivery system of FIG.1 a.

FIG. 2 a illustrates a delivery system comprising a relatively widetubular covering and a particulated substance, in accordance with oneembodiment.

FIG. 2 b illustrates an alternative view of the delivery system of FIG.2 a.

FIG. 3 illustrates a two-compartment covering comprising twosingle-compartment coverings coupled together, in accordance with oneembodiment.

FIG. 4 illustrates a tubular covering for delivery in a catheter, inaccordance with one embodiment.

FIG. 5 a illustrates a perspective view of a covering having anelongated containment portion, in accordance with one embodiment.

FIG. 5 b illustrates a top view of the covering of FIG. 5 a.

FIG. 5 c illustrates an end cross-sectional view of the covering of FIG.5 a.

FIG. 6 a illustrates a perspective view of an alternative embodiment ofa covering having an elongated containment portion.

FIG. 6 b illustrates a top view of the covering of FIG. 6 a.

FIG. 6 c illustrates an end cross-sectional view of the covering of FIG.6 a.

FIG. 7 a illustrates a perspective view of yet an alternative embodimentof a covering having an elongated containment portion.

FIG. 7 b illustrates a top view of the covering of FIG. 7 a.

FIG. 7 c illustrates an end cross-sectional view of the covering of FIG.7 a.

FIG. 8 illustrates a first embodiment of a multi-compartment coveringhaving an elongated containment portion.

FIG. 9 illustrates a second embodiment of a multi-compartment coveringhaving an elongated containment portion.

FIG. 10 illustrates a dual-compartment covering comprising first andsecond compartments situated side-by-side and separated by a barrier, inaccordance with one embodiment.

FIG. 11 illustrates a nested dual-compartment covering, in accordancewith one embodiment.

FIG. 12 illustrates a covering comprising as a plurality of compartmentsseparated by perforations, in accordance with one embodiment.

FIG. 13 a illustrates a covering having a hook attachment mechanism, inaccordance with one embodiment.

FIG. 13 b illustrates a covering having a screw attachment mechanism, inaccordance with one embodiment.

FIG. 13 c illustrates a covering having a mechanical attachmentmechanism, in accordance with one embodiment.

FIG. 13 d illustrates a covering having a suture attachment mechanism,in accordance with one embodiment.

FIG. 13 e illustrates a covering having a wrap attachment mechanism, inaccordance with one embodiment.

FIG. 13 f illustrates a covering having an adhesive attachmentmechanism, in accordance with one embodiment.

FIG. 13 g illustrates a covering having an adhesive attachmentmechanism, in accordance with a further embodiment.

FIG. 14 a illustrates a tension band and covering embodiment, inaccordance with one embodiment.

FIG. 14 b illustrates tension band comprising covering includingspreaders, in accordance with one embodiment.

FIG. 15 illustrates a covering being loaded with a substance using asyringe, in accordance with one embodiment.

FIG. 16 illustrates a tubular covering partially divided intocompartments, in accordance with one embodiment.

DEFINITIONS

Bioactive Agent or Bioactive Compound, as used herein, refers to acompound or entity that alters, inhibits, activates, or otherwiseaffects biological or chemical events. For example, bioactive agents mayinclude, but are not limited to, osteogenic or chondrogenic proteins orpeptides, anti-AIDS substances, anti-cancer substances, antibiotics,immunosuppressants, anti-viral substances, enzyme inhibitors, hormones,neurotoxins, opioids, hypnotics, anti-histamines, lubricants,tranquilizers, anti-convulsants, muscle relaxants and anti-Parkinsonsubstances, anti-spasmodics and muscle contractants including channelblockers, miotics and anti-cholinergics, anti-glaucoma compounds,anti-parasite and/or anti-protozoal compounds, modulators ofcell-extracellular matrix interactions including cell growth inhibitorsand antiadhesion molecules, vasodilating agents, inhibitors of DNA, RNAor protein synthesis, anti-hypertensives, analgesics, anti-pyretics,steroidal and non-steroidal anti-inflammatory agents, anti-angiogenicfactors, angiogenic factors, anti-secretory factors, anticoagulantsand/or antithrombotic agents, local anesthetics, ophthalmics,prostaglandins, anti-depressants, anti-psychotic substances,anti-emetics, and imaging agents. In certain embodiments, the bioactiveagent is a drug. In some embodiments, the bioactive agent is a growthfactor, cytokine, extracellular matrix molecule or a fragment orderivative thereof, for example, a cell attachment sequence such as RGD.A more complete listing of bioactive agents and specific drugs suitablefor use in the present invention may be found in “PharmaceuticalSubstances: Syntheses, Patents, Applications” by Axel Kleemann andJurgen Engel, Thieme Medical Publishing, 1999; the “Merck Index: AnEncyclopedia of Chemicals, Drugs, and Biologicals”, Edited by SusanBudavari et al., CRC Press, 1996; and the United StatesPharmacopeia-25/National Formulary-20, published by the United StatesPharmcopeial Convention, Inc., Rockville Md., 2001, each of which isincorporated herein by reference.

Biocompatible, as used herein, refers to materials that, uponadministration in vivo, do not induce undesirable long-term effects.

Bone, as used herein, refers to bone that is cortical, cancellous orcortico-cancellous of autogenous, allogenic, xenogenic, or transgenicorigin.

Demineralized, as used herein, refers to any material generated byremoving mineral material from tissue, e.g., bone tissue. In certainembodiments, the demineralized compositions described herein includepreparations containing less than 5% calcium and preferably less than 1%calcium by weight. Partially demineralized bone (e.g., preparations withgreater than 5% calcium by weight but containing less than 100% of theoriginal starting amount of calcium) is also considered within the scopeof the invention. In some embodiments, demineralized bone has less than95% of its original mineral content. Demineralized is intended toencompass such expressions as “substantially demineralized,” “partiallydemineralized,” and “fully demineralized.”

Demineralized bone matrix, as used herein, refers to any materialgenerated by removing mineral material from bone tissue. In preferredembodiments, the DBM compositions as used herein include preparationscontaining less than 5% calcium and preferably less than 1% calcium byweight. Partially demineralized bone (e.g., preparations with greaterthan 5% calcium by weight but containing less than 100% of the originalstarting amount of calcium) are also considered within the scope of theinvention.

Osteoconductive, as used herein, refers to the ability of anon-osteoinductive substance to serve as a suitable template orsubstance along which bone may grow.

Osteogenic, as used herein, refers to the ability of an agent, material,or implant to enhance or accelerate the growth of new bone tissue by oneor more mechanisms such as osteogenesis, osteoconduction, and/orosteoinduction.

Osteoimplant, as used herein, refers to any bone-derived implantprepared in accordance with the embodiments of this invention andtherefore is intended to include expressions such as bone membrane, bonegraft, etc.

Osteoinductive, as used herein, refers to the quality of being able torecruit cells from the host that have the potential to stimulate newbone formation. Any material that can induce the formation of ectopicbone in the soft tissue of an animal is considered osteoinductive. Forexample, most osteoinductive materials induce bone formation in athymicrats when assayed according to the method of Edwards et al.,“Osteoinduction of Human Demineralized Bone: Characterization in a RatModel,” Clinical Orthopaedics & Rel. Res., 357:219-228, December 1998,incorporated herein by reference.

Superficially demineralized, as used herein, refers to bone-derivedelements possessing at least about 90 weight percent of their originalinorganic mineral content, the expression “partially demineralized” asused herein refers to bone-derived elements possessing from about 8 toabout 90 weight percent of their original inorganic mineral content andthe expression “fully demineralized” as used herein refers to bonecontaining less than 8% of its original mineral context.

DETAILED DESCRIPTION

I. Introduction

A delivery system for delivering a substance or material to a surgicalsite is provided. The delivery system comprises a covering and asubstance wherein the substance is provided within the covering fordelivery to the surgical site. Generally, the covering may be a singleor multi-compartment structure capable of at least partially retaining asubstance provided therein until the covering is placed at a surgicalsite. Upon placement, the covering facilitates transfer of the substanceand/or materials surrounding the surgical site. The covering mayparticipate in, control, or otherwise adjust, the release of thesubstance or penetration of the covering by surrounding materials, suchas cells or tissues. The covering may include one or more attachmentmechanisms for retaining the covering at the surgical site. Theattachment mechanism may be a mechanical attachment mechanism, aphysical attachment mechanism, a biological attachment mechanism or achemical attachment mechanism, or may employ combinations of these. Theattachment mechanism may be used to attach the covering to skeletal orsoft tissue proximate the surgical site.

In some embodiments, the covering may be used for containment ofparticulate or morselized materials (the substance provided in thecovering), optionally to provide a focus or concentration of biologicalactivity. In some embodiments, the covering may be used for maintainingmaterials (the substance provided in the covering) in spatial proximityto one another, possibly to provide a synergistic effect. In someembodiments, the delivery system may be used to control availability ofa substances provided within the delivery system to cells and tissues ofa surgical site over time. In some embodiments, the delivery system maybe used for delivery through a limited opening, such as in minimallyinvasive surgery or mini-open access. In some embodiments, the deliverysystem may be used to deliver morselized or particulated materials (thesubstance provided in the covering) in pre-measured amounts. In otherembodiments, the substance may be liquid or flowable, or combinations ofthese with particulate, morselized, and/or other materials.

In various embodiments, the covering may contain a substance or materialsuch as a graft material. The covering limits, and in some embodimentseliminates graft migration and maintains graft density. The deliverysystem, with contained substance or material, may be configured toconform to surrounding bony contours or implant space. In someembodiments, the delivery system provides a pathway for healing/cellpenetration and tissue ingrowth. Thus, the covering may facilitatetransfer of a substance out of the covering or transfer or surroundingmaterials at the surgical site, such as cells and tissues, into thecovering.

The covering may have a single compartment or may have a plurality ofcompartments. Thus, in one embodiment, the covering is dual-compartmentand comprises first and second compartments. A first substance may beprovided in the first compartment and a second substance may be providedin the second compartment. The second compartment may be adjacent to,apart from, inside, or surrounding the first compartment. Materialsforming the first compartment and the second compartment may be the sameor different. Selection of materials, positioning of the compartments,and other factors relating to the first and second compartments may bechosen to achieve simultaneous or sequential delivery or release of asubstance or substances.

II. Covering Material

The covering may comprise a structural material and, in someembodiments, a functional material. The structural material may comprisea mesh material, a polymeric material, or other. The functional materialmay comprise, for example, a radiopaque material, a bacteriocidalmaterial, or other.

Structural Material Characteristics

In various embodiments, in accordance with the specific application forwhich the covering is being used, the covering may be rigid, may beflexible, may be non-elastic, or may be elastic. The covering materialmay be braided, woven, non-woven shape memory, particulate, threaded,porous, or non-porous.

The covering may participate in, control, or otherwise adjust therelease of the substance. For example, the covering may act as aselectively permeable membrane and/or may be porous, with the level ofporosity being related to the nature of the substances inside thecovering. Thus, the material for and configuration of the covering maybe selected or adjusted based on desired release characteristics.Specific properties that may be adjusted include thickness,permeability, porosity, strength, flexibility, elasticity, and others ofthe covering material. It is to be appreciated that some of theseproperties may depend on others. For example, the thickness and porosityof the material may contribute to its strength, flexibility, andelasticity.

In some embodiments, the covering may be porous to fluid and/or cells,may be biocompatible, and may be resistant to rupture (including shouldthe substance provided therein swell). In some embodiments, the coveringwith the substance provided therein may be loadbearing. The covering maybe resorbable or non-resorbable. The covering may provide increasedhandling properties, may have irrigation resistance, and/or may supportcellular penetration. Flexibility of the covering may be selected tosuit particular applications. In some applications, it may be desirableto have a flexible covering.

If the covering is made from a resorbable material, the coveringdegrades and disappears after a period of time. If the covering is notmade of a resorbable material, the covering remains in the body. Tissueingrowth may occur to bind the host tissue to the substance providedwithin the covering. Tissue ingrowth through and around the covering,between the host tissue and the substance provided within the covering,may be promoted via openings in the covering.

In various embodiments, the covering may comprise a porous material or amesh material. The size of the pores of the covering may be designed topermit cellular infiltration (approximately several microns to severalmillimeters), but may also be designed specifically to exclude cells forthe inside of the covering (e.g. approximately 0.45 microns) and onlyallow diffusion of small molecules (proteins and hormones). Thus, thecovering may act to control access to the interior of the deliverysystem by cells. In embodiments comprising more than one compartment,characteristics of the covering material may be varied betweencompartments. Generally, the porosity, flexibility, strength, or anyother characteristic of one compartment may vary from thatcharacteristic of the other compartment. U.S. Patent ApplicationPublication No. 2005/0283255 for Tissue-Derived Mesh for OrthopedicRegeneration describes suitable manners for forming a mesh for use witha covering as provided herein and is herein incorporated by reference inits entirety.

The covering may be formed of a resorbable or nonresorbable, natural orsynthetic biocompatible material. In some embodiments, more than onematerial may be used, including as multiple layers. For example, in anembodiment comprising two compartments, one or more materials may beused for the first compartment and a different material or materials maybe used for the second compartment. For example, one compartment orportions thereof may be made of material or materials that provide adesired property or properties relative to other compartments orportions thereof, such as increased or decreased resorbability orstiffness, or the different compartments or portions thereof may beimparted with different drug delivery properties, etc. Alternatively,all compartments may comprise the same material or mixtures ofmaterials. Where the characteristics of the material are varied betweencompartments, or over the surface of a single compartment, the pores ofthe first compartment or portion thereof may be larger than the pores ofthe second compartment.

The covering may comprise any suitable structure for delivering asubstance in vivo. Thus, as described, the covering may comprise a mesh.In other embodiments, the covering may comprise a polymeric structurewith a chamber provided therein. The chamber may be filled with asubstance for delivering in vivo, such as autograft, demineralized bonematrix, or others disclosed herein.

In some embodiments, the covering may expand when placed in the body.Expansion can be provided in at least two ways: the covering may becompressed such that the covering expands when placed in the body or thecovering may be made of a material that expands when it comes in contactwith water or other bodily fluids, either by way of liquid absorption,or by stretching when the materials inside it absorb liquid andthemselves expand. In some embodiments, the covering may comprise ashape memory material such as copper-zinc-aluminum-nickel alloy,copper-aluminum-nickel alloy, and nickel-titanium (NiTi) alloy.Reinforcing materials such as cortical bone, calcium phosphates, etc.may be incorporated into the structure of the covering to reinforce it.

The covering may be configured for specific compressive strength andrigidity by adjusting density and resorption time of the covering. Insome embodiments, a coating may be provided over the covering. Forexample, the coating may be a compound of poly-L-lactide, ofpolyglycolic acid, or their polymers, or polyhydroxyalkanoates(polyhydroxybutyrates and polyhydroxyvalerates and copolymers). Thecoating may be selected such that it has a resorption time wherein it isresorbed by the body and the material within the covering is permittedto exit through openings in the covering.

Exemplary Covering Materials

Polymeric material (for example, see U.S. Pat. Nos. 6,696,073,6,478,825, 6,440,444, and 6,294,187 and U.S. Patent Publications Nos.2006/0216323 and 2005/0251267, all herein incorporated by reference intheir entirety); woven material and braided material (for example, seeU.S. Patent Publication No. 2005/0283255, herein incorporated byreference in its entirety); non-woven; shape memory material; usingouter particles to contain inner particles; attach particles to threads;add porosity to mesh fibers; non-porous materials; non-porous materials.In some embodiments, materials may be used for portions of the covering,such as for a compartment of the covering, that are substantiallyimpenetrable.

In some embodiments, the covering may comprise a mesh material. Suitablemesh materials include natural materials, synthetic polymeric resorbablematerials, synthetic polymeric non-resorbable materials, and othermaterials. Natural mesh materials include silk, extracellular matrix(such as DBM, collagen, ligament, tendon tissue, or other),silk-elastin, elastin, collagen, and cellulose. Synthetic polymericresorbable materials include poly(lactic acid) (PLA), poly(glycolicacid) (PGA), poly(lactic acid-glycolic acid) (PLGA), polydioxanone, PVA,polyurethanes, polycarbonates, polyhydroxyalkanoates(polyhydroxybutyrates and polyhydroxyvalerates and copolymers), andothers. See Chen and Wu, “The Application of Tissue EngineeringMaterials,” Biomaterials, 2005, 26(33): p. 6565-78, herein incorporatedby reference in its entirety. Other suitable materials include carbonfiber, metal fiber, and various meshes. In other embodiments, thecovering may comprise non-woven material such as spun cocoon or shapememory materials having a coil shape or shape memory alloys.

Generally, the covering may be formed of any natural or syntheticstructure (tissue, protein, carbohydrate) that can be used to form acovering configuration. Thus, the covering may be formed of a polymer(such as polyalkylenes (e.g., polyethylenes, polypropylenes, etc.),polyamides, polyesters, poly(glaxanone), poly(orthoesters),poly(pyrolicacid), poly(phosphazenes), polycarbonate, otherbioabsorbable polymer such as Dacron or other known surgical plastics, anatural biologically derived material such as collagen, gelatin,chitosan, alginate, a ceramic (with bone-growth enhancers,hydroxyapatite, etc.), PEEK (polyether-etherketone), dessicatedbiodegradable material, metal, composite materials, a biocompatibletextile (e.g., cotton, silk, linen), extracellular matrix components,tissues, or composites of synthetic and natural materials, or other.Various collagen materials can be used, alone or in combination withother materials, including collagen sutures and threads. Any suitablecollagen material may be used, including known collagen materials, orcollagen materials as disclosed in U.S. patent application Ser. No.12/030,181, filed Feb. 12, 2008, hereby incorporated by reference in itsentirety, which discloses collagen materials that may be used forforming a covering. Some examples include polymer or collagen threadswoven, or knitted into a mesh. Other suitable materials include thinpolymer sheets molded in the presence of a porogen and having underwentleaching; polymer sheets or naturally derived sheets such as fascia andother collagen materials, small intestinal submucosa, or urinary bladderepithelium, the sheets being punctured to introduce porosity; specificshapes printed using available or future printing technologies;naturally secreted materials such as bacterial cellulose grown withinspecific molds; etc.

In some embodiments, mesh fibers may be treated to impart porosity tothe fibers. This may be done, for example, to PLA, PLGA, PGA, and otherfibers. One suitable method for treating the mesh fibers comprisessupercritical carbon dioxide treatment to partially solubilize theparticles. This treatment may further be carried out for viralinactivation. Another suitable method for treating the mesh fiberscomprises explosive decompression. Explosive decompression generatesporosity and leads to controlled permeability. The mesh material furthermay be loaded with cells, growth factors, or bioactive agents.

In further embodiments, fibers of a mesh material may be treated such asby having particles adhered thereto. The particles may be, for example,bone particles. Thus, in one embodiment, the covering may comprise aplurality of threads formed into a fabric. The threads may haveparticles adhered thereto. For example, the threads may have particlesstrung on the thread. In an alternative embodiment, the covering may beformed of a material and the material may be coated with particles.

In yet other embodiments, the covering may comprise a non-porousmaterial, which may be permeable. A non-porous material may be used forlater (or delayed) delivery of a substance provided therein. Suchsubstance may comprise, for example, cells, growth factors, or bonemorphogenetic proteins. Accordingly, in one embodiment, a deliverysystem for delayed delivery of cells, growth factors, or bonemorphogenetic proteins is provided comprising a non-porous covering.

Functional Material Characteristics

The covering material may have functional characteristics.Alternatively, other materials having functional characteristics may beincorporated into the covering. Functional characteristics may includeradiopacity, baceriocidity, source for released materials, etc.

Suitable radiopaque materials include, for example, ceramics,mineralized bone, ceramics/calcium phosphates/calcium sulfates, metalparticles, fibers, and iodinated polymer (see, for example,WO/2007/143698). Suitable bacteriocidal materials may include, forexample, trace metallic elements. In some embodiments, trace metallicelements may also encourage bone growth.

The covering itself may be designed to release materials duringdegradation of the covering material. Thus, bone morphogenic proteins(BMPs), growth factors, antibiotics, angiogenesis promoting materials(discussed more fully below), bioactive agents (discussed more fullybelow), or other actively releasing materials may be incorporated intothe covering material such that as the covering material is degraded inthe body, the actively releasing material is released. For example, anactively releasing material may be incorporated into a biodegradablepolymer covering such as one manufactured of a biodegradable polyestersuch as poly(lactic acid) (PLA), poly(glycolic acid) (PGA),poly(lactic-co-glycolic acid) (PLGA), or polyhydroxyalkanoates(polyhydroxybutyrates and polyhydroxyvalerates and copolymers). In someembodiments, poly(ethylene glycol) (PEG) may be incorporated into thebiodegradable polyester to add hydrophilic and other physico-chemicalproperties to enhance drug delivery. In some embodiments, composites ofallograft bone and biodegradable polymers (for example, PLEXUR® productsavailable from Osteotech) may be used in the covering.

In one embodiment of a covering comprising two compartments, first andsecond materials may be used for the first and second compartments,respectively. The first material may release a growth factor accordingto a first rate and the second material may release a growth factoraccording to a second rate. Further, the growth factors released by thefirst and second compartments may be the same or may be different. Forexample, an angiogenic growth factor may be provided with the firstcompartment and an osteoinductive growth factor may be provided with thesecond compartment.

Mesh Formulation

Any suitable technique may be used for forming a material for thecovering. In one embodiment, elongated bone-derived particles orfragments of small intestinal submucosa (for example, approximately 6)may be combined longitudinally into three small bundles, each having,for example, from about 1 to about 3 tissue particles. The three bundlesmay then braided. Various methods of braiding and types of braids any ofwhich may be useful in producing the material of the invention hereinare also described, e.g., by Shaw, KNOTS—Useful & Ornamental, BonanzaBooks, New York (1983), incorporated herein by reference. The ends ofthe braided tissue-derived particles may then be glued together using afixation agent to prevent their unraveling, or they may be held togetherwith a biocompatible polymer or metal band.

In an alternative embodiment, bone-derived particles are combined with asolvent to form a material. Exemplary solvents include water, loweralkanols, ketones, and ethers and mixtures of any of these or othermaterials. The material may then extruded at an appropriate temperatureand pressure to create a thread. Threads may also be produced byspinning, drawing, rolling, solvent-extruding, cutting or laser cuttingfrom a sheet or bar stock. The material may alternatively be cast ormolded into a solid sheet or bar stock and then cut into thin threads.These may be used immediately or woven into a mesh. Alternatively or inaddition, they may be spliced, wrapped, plied, cabled, braided, woven,or some combination of these. The material may be shaped by thermal orchemical bonding, or both. In one embodiment, a portion of the solventis removed from the material before extrusion.

Alternatively or in addition, the material may be cast as a slurry,extruded, or molded. A variety of materials processing methods will bewell known to those skilled in the art. For example, the material may besolvent cast using a press such as a Carver press to spread the materialinto a film. Solvent evaporation will yield a porous film.Alternatively, the material may be compression molded into a film. Themesh size or porosity of the film will depend on the thickness of thefilm and the viscosity of the precursor and can be easily manipulated byone skilled in the art. Where elongated particles are used in anextruded aggregate, they will tend to be aligned roughly parallel to oneanother.

In an alternative embodiment, a thread of a biocompatible natural orsynthetic material, for example, polylactide or collagen, may be coatedwith tissue-derived or other elements, for example, by dubbing. Forexample, a polymer fiber may be coated with an adhesive, for example,lecithin, and bone particles or other osteoconductive or osteoinductivefibrils allowed to adhere to the thread. The thread may then be twistedon itself or with a second or a plurality of similarly treated threads.Alternatively or in addition, the threads may be braided. The adhesivemay be a lipid that is waxy at room temperature, for example, a di- ortriglyceride that is solid at room temperature. Alternatively or inaddition, the adhesive may be a phosphocholine or phosphatidylcholine.In some embodiments, the adhesive is a material that binds both thethread and the material that is used to coat the thread (e.g., boneparticles) but that does not degrade either. Non-aqueous adhesives mayimprove the stability of the final aggregate as compared to aqueousadhesives.

Suitable fibers may be formed utilizing well known techniques, e.g.,braiding, plying, knitting, weaving, felting, that are applied toprocessing natural fibers, e.g., cotton, silk, etc., and syntheticfibers made from synthetic bioabsorbable polymers, e.g., poly(glycolide)and poly(lactic acid), nylon, cellulose acetate, etc. See, e.g.,Mohamed, American Scientist, 78: 530-541 (1990). For example, U.S. Pat.No. 5,378,469, herein incorporated by reference in its entirety,describes the braiding of crosslinked and noncrosslinked collagenthreads using a harness braiding machine (New England Butt Co.,Providence, R.I.). Specifically, collagen thread is wound ontocylindrical stainless steel spools. The spools are then mounted onto thebraiding carousel, and the collagen thread is then assembled inaccordance with the instructions provided with the braiding machine. Inone particular run, a braid was formed of four collagen threads, whichconsisted of two threads of uncrosslinked collagen and two threads ofcrosslinked collagen. One skilled in the art will recognize that thesetechniques may be applied to the other fibrous materials describedherein.

Fibers and more evenly dimensioned particles may also be plied intoyarns using the same methods and same machinery known to those skilledin the art in plying threads made out of other material, e.g., cotton,polyester, etc. For example, U.S. Pat. No. 5,378,469 describes theproduction of a 60 ply yarn from noncrosslinked collagen threads. Fourcollagen threads were twisted together. Three of the resultant 4-plystrands were then twisted together in the opposite direction, and then 5of the resultant 12 ply strands were twisted in the opposite direction.

Elongated materials including multistranded materials, e.g., braids,plied yams, cables, etc., may be knitted into tubular or flat fabrics byusing techniques known to those skilled in the art of producing fabricsmanufactured from other types of threads. Various biologically activesubstances can be incorporated in, or associated with, the braided,knitted, or woven materials. Particles and fibers and materials of these(including multistranded materials) may alternatively or additionally beassembled into a material by non-woven methods such as laying,needle-punching, and hooking (as for a rug). For example, a thread maybe attached to another thread or a pressed film.

Regardless of the assembly method, the material shape, mesh size, cablethickness, and other structural characteristics, e.g., architecture, maybe customized for the desired application. For example, where a twodimensional aggregate is used to retain a thixotropic material within agap, a tight weave is preferred to prevent leakage. To optimize cell orfluid migration through the mesh, the pore size may be optimized for theviscosity and surface tension of the fluid or the size of the cells. Forexample, pore sizes on the order of approximately 100-200 μm may be usif cells are to migrate through the mesh. Mesh size may be controlled byphysically weaving strands of the material by controlling the ratio ofsolvent to solids in a precursor material.

Cells may be seeded onto the material. In one embodiment, cells may beencapsulated in a matrix such as alginate or collagen gel and thecapsules placed on the material. Methods for encapsulating cells arewell known to those skilled in the art; an exemplary method is disclosedin U.S. Pat. No. 4,391,909, herein incorporated by reference in itsentirety. Seeded materials generally do not need to be incubated forlong periods of time in solutions that could partially dissolve thebinding agent. Instead, the capsules may be placed on the material orcovering shortly before implantation. In another embodiment, cells aresimply mixed with a gel which is then combined with the material.Alternatively, a material or covering may be cultured with cells beforeimplantation. In one embodiment, thicker materials are used forculturing to increase mechanical integrity during implantation. Anyclass of cells, including connective tissue cells, organ cells, musclecells, nerve cells, and stem cells, may be seeded onto the implant. Inan exemplary embodiment, connective tissue cells such as osteoblasts,osteoclasts, fibroblasts, tenocytes, chondrocytes, and ligament cellsand partially differentiated stem cells such as mesenchymal stem cellsand bone marrow stromal cells are employed.

III. Covering Configuration or Form

The shape, configuration, or form of the covering may be selected forparticular applications. Such shape and configuration may include, forexample, the basic shape of the covering (e.g., a cylinder), whether thecovering has a single or a plurality of compartments, and whether thecovering includes attachment mechanisms. The covering (or deliverysystem) may be configured to conform to surrounding bony contours of thespace in which it is placed.

Form

As previously discussed, the covering may be formed of as a mesh. Thus,the covering may comprise a woven material. The woven material may havevarying degrees of permeability. It may be permeable, semi-permeable, ornon-permeable. Permeability may be with respect to cells, to liquids, toproteins, to growth factors, to bone morphogenetic proteins, or other.In further embodiments, the material may be braided.

In alternative embodiments, the covering may comprise a substantiallysolid structure, such as a polymer structure with a chamber, or a spuncocoon.

Shape

The covering may have any suitable configuration. For example, thecovering may be formed as a ring, a cylinder, a cage, a rectangularshape, a mesh, a suture-like wrap, a continuous tube, or otherconfiguration. In specific embodiments, the covering may be formed as athin tube (having, for example, a diameter of approximately 4-6 mm)designed to be inserted through catheters, a rectangular shape designedto fit adjacent to spinal processes for PLF, a cube like structuredesigned to fit between vertebral bodies or within cages for interbodyspinal fusion, a tube like shape where the ends are designed to befitted onto nonunion long bone defects, relatively flat shapes designedto fill cranial or maxillofacial defects, rectangular structuresdesigned for osteochondral defects, structures preshaped to fit aroundvarious implants (e.g. dental, doughnut with hole for dental implants),or relatively elastic ring-like structures that will stretch and thenconform to shapes (e.g. rubber band fitted around processes). In anembodiment wherein the covering is formed as a cage, the cage maycomprise a plurality of crossed filaments which define between them aseries of openings for tissue ingrowth. Any of these shapes may be usedfor a covering comprising a plurality of compartments. For example, in atubular embodiment, the tube may be formed into a plurality ofcompartments by tying a cord around the tube at one or more points, orby other suitable mechanism such as crimping, twisting, knotting,stapling, sewing, or other. The configuration of the covering may bedetermined by the substance to be provided within the covering. Forexample, if the substance to be contained comprises fibers, the coveringmay be formed as strings or sutures that are wrapped around the fibers.

FIGS. 1 a and 1 b illustrate a delivery system comprising tubularcovering 10 and particulated substance. In the embodiment of FIGS. 1 aand 1 b, the covering 10 is relatively narrow. In contrast, FIGS. 2 aand 2 b illustrate a delivery system comprising relatively wide covering20. In the embodiments shown in FIGS. 1 a, 1 b, 2 a, and 2 b, thecoverings 10, 20 comprise a mesh material. The particulated substance isprovided within the coverings 10, 20.

A covering as provided herein may further comprise an attachment orcoupling mechanism. Any suitable attachment mechanism can be used, suchas a tab, loop, tack or other structure adapted for attachment at thesite. Also, for example, a covering may include a hook-and-eye (Velcro)portion. The hook-and-eye portion may be used to couple the covering toa tissue structure, such as bone, or to another covering. For example,as shown in FIG. 3, a dual compartment covering 21 may be formed by twosingle-compartment coverings 22, 24 coupled at portion 26 atcomplementary ends thereof. In the embodiment shown, the couplingportion 26 may comprise overlapping/mating Velcro portions. The size andshapes of the single compartment coverings 22, 24 may be the same or maybe different. Further, the materials of the compartment coverings 22, 24and the substances provided therein may be the same or may be different.The coupling may be done pre-implantation or post-implantation. Inpost-implantation embodiments, the coupling may be done by insertingfirst and second coverings through an opening into a space and couplingthe coverings within the space. Other suitable attachment, or coupling,mechanisms are described more fully below.

Compartments

Single Compartment

As shown in FIGS. 1 a, 1 b, 2 a, and 2 b, the covering may comprise asingle compartment covering 10, 20. Those figures illustrated generallytubular embodiments. In further embodiments, such as shown in FIG. 4 thecovering 30 may be a narrow tube for delivery through a catheter 32. Forexample, the covering may be delivered percutaneously using a catheterthrough which it is inserted. Thus, as shown, the covering 30 may havedimensions suitable for receipt in the catheter. Optionally, thecovering 30 may be stiffened to facilitate insertion into the catheter32. Such stiffening may be achieved through choice of material for thecovering, by treating the material of the covering, or other. In someembodiments, the covering 30 may be coated with a material to facilitatesliding engagement with the catheter 32.

FIGS. 5 a-5 c illustrate a covering embodiment 200 having an elongatedcontainment portion 202 for housing a substance for delivery, and havingfirst and second ends 204, 206. One or both of the first and second ends204, 206 may have an attachment mechanism 208. Any suitable attachmentmechanism may be used. In the embodiment shown, each of the first andsecond ends 204, 206 comprises a tab attachment mechanism 208. One orboth of the first and second ends 204, 206 further may be sealed. In theembodiment shown, the first end 204 is sealed. The seal 210 may comprisea portion of the tab 108, as shown, or may be separate from the tab 108.The seal 210 may have a width and a thickness suitable for maintaining aseal with the substance provided within the containment portion. Forexample, the seal 210 may have a length of approximately 0.6 cm, withthe tab 208, including the seal 210, having a length of approximately1.0 cm. Accordingly, the tab 108 is coextensive with the seal 210 forapproximately 0.6 cm and extends approximately 0.4 cm beyond an outeredge of the seal 210. In some embodiments, one or both ends 204, 206 maybe unsealed such that the covering 200 may be filled with a substanceand sealed, for example via heat sealing, in the operating room. Theelongated containment portion 202 comprises a length, a width, and across section. The length may be, for example, approximately 5 cm,approximately 10 cm, approximately 20 cm, or any other suitable length.The width may be, for example, approximately 1 cm. The length to widthratio may vary depending on application. In the embodiment of FIGS. 5a-5 c, the containment portion 202 has a generally circularcross-sectional shape with an approximately 1.0 cm diameter. Whileexemplary dimensions are provided with respect to FIGS. 5 a-5 c, thesedimensions are intended for illustration only and are not limiting.

FIGS. 6 a-6 c illustrate an alternative embodiment of a covering 220having an elongated containment portion 222 for housing a substance fordelivery, and having first and second ends 224, 226. In the embodimentof FIGS. 6 a-6 c the containment portion 222 has a generally ovalcross-sectional shape. In various embodiments, the covering 220 may havea width of approximately 2.5 cm, a containment portion 222 length ofapproximately 5 cm or approximately 10 cm, and a tab 228 length ofapproximately 0.5 cm. In the embodiment of FIGS. 6 a-6 c, a seal 230 isprovided at the first end of the covering and extends over substantiallythe entire length of the tab 228 at the first end 224. While exemplarydimensions are provided with respect to FIGS. 6 a-6 c, these dimensionsare intended for illustration only and are not limiting.

FIGS. 7 a-7 c illustrate an alternative embodiment of a covering 240having an elongated containment portion 242 for housing a substance fordelivery, and having first and second ends 244, 246. The embodiment ofFIGS. 7 a-7 c is substantially similar to the embodiment of FIGS. 6 a-6c except for the tabs 248 at the first and second ends 244, 246. In theembodiment of FIGS. 7 a-7 c, the tabs 248 have a length of approximately1.0 cm and the associated seal 250 of the tab at the first end 244 has alength of approximately 0.6 cm. Accordingly, the tab 248 is coextensivewith the seal 250 for approximately 0.6 cm and extends approximately 0.4cm beyond an outer edge of the sea 2501. While exemplary dimensions areprovided with respect to FIGS. 7 a-7 c, these dimensions are intendedfor illustration only and are not limiting.

FIGS. 5 a-5 c, 6 a-6 c, and 7 a-7 c illustrate various alternativeembodiments of a covering having an elongated containment portion forhousing a substance for delivery, and having first and second ends. Ineach of the embodiments shown, the first and second ends include a tabattachment mechanism. In alternative embodiments, only one of the endsmay have an attachment mechanism. Further, the attachment mechanism mayhave an alternative configuration, such as a bore for receiving a screw.FIGS. 5 a-5 c, 6 a-6 c, and 7 a-7 c illustrate generally circular andgenerally oval cross-sectional shapes. In alternative embodiments, anycross-sectional shape, such as a generally rectangular, generallysquare, generally star, or any other suitable shape. The length, width,and length-to-width ratio may vary depending on the application for thecovering.

In a further single compartment covering embodiment, the covering may beused in a variation of the Masquelet technique. The Masquelet techniqueis used in long bone trauam applications where there is a largeinterclarary defect, such as where a segment of a long bone is missing.The Masquelet technique typically comprises two stages, a first stagewherein a spacer is placed and soft tissue forms around the spacer, anda second stage wherein the formed soft tissue is used to cover the bonegraft. In some embodiments, a covering such as provided herein may beused for trauma repair in a long bone segmental defect. For example, arelatively large covering may be provided with a substance providedtherein suitable for trauma repair where the covering is used to holdthe space (excluding soft tissue) in the long bone and have soft tissueform therearound. The second step of the Masquelet technique may beavoided because graft materials are provided when the covering isoriginally placed.

In one embodiment of a single compartment covering, a plurality ofsubstances may be provided within the covering based on characteristicsof the substances. For example, where it is desirable to include aparticulated first substance within a material having mesh openingslarger than the substance, a second substance may be providedsurrounding the particulated first substance to reduce the likelihood ofrelease of particles of the first substance from the mesh. Thus, forexample, a particulated first substance and a particulated secondsubstance may be provided wherein the particles of the first substancehave a smaller size than the particles of the second substance. Acovering is provided comprising a mesh having mesh openings or poreslarger than the particles of the first substance. For use, the firstsubstance is provided generally centrally within the covering, thesecond substance is provided around the first substance and thus betweenthe first substance and the second substance. In further embodiments,the second substanced may be coated, for example via spray coating orsolvent casting.

In yet a further embodiment, a single compartment covering may be usedas a spacer for nonunion. For example, the covering may be placed in acanal of a long bone.

Multi Compartment

In alternative embodiments, and as briefly discussed with respect toFIG. 3, the covering may comprise a plurality of compartments. Forexample, the covering may comprise nested coverings, coverings coupledvia a temporary barrier, coverings separated with a boundary, andothers, described below. In embodiments comprising two compartments, asecond compartment may be adjacent, apart from, inside, or surrounding afirst compartment. Materials for first compartment and the secondcompartment (which may be designated first and second substances) may bethe same, partially the same, or different. The materials for the firstcompartment and the second compartment may have different releaseprofiles, different porosities, and other different characteristics.Selection of materials, positioning of the compartments, and otherfactors relating to the first and second compartments may be chosen toachieve simultaneous or sequential delivery or release of a substance orsubstances. A first substance may be provided in the first compartmentand a second substance may be provided in the second compartment. Insome embodiments, an osteoinductive substance may be placed in acompartment generally adjacent tissue being treated as implanted and anosteoconductive substance may be placed in a compartment not adjacenttissue being treated. Release rates for the materials provided in thefirst compartment and the second compartment may be different. In someembodiments, at least one of the compartments may be unfilled at thetime of surgery and autograft or other material may be provided thereinin the operating room or at the surgical site. In some embodiments, thecovering may form a 3D scaffold.

The embodiments of FIGS. 5 a-5 c, 6 a-6 c, and 7 a-7 c may further beconfigured as multi-compartment embodiments. FIG. 8 illustrates anexemplary multi-compartment embodiment of a covering 260 having anelongated containment portion 262 for housing a substance for delivery,and having first and second ends 264, 266. In the embodiment of FIG. 8,the elongated containment portion 262 comprises first and secondcompartments 268, 270 extending substantially the entire length of theelongated containment portion 262. As shown, the first and secondcompartments 268, 270 extend side-by-side with each of the first andsecond compartments 268, 270 extending from the first end 264 of thecovering 260 to the second end 266 of the covering 260. Alternatively,the first and second compartments may extend one over the other, such asthe first compartment arranged over the second compartment.

FIG. 9 illustrates an exemplary multi-compartment embodiment of acovering 280 having an elongated containment portion 282 for housing asubstance for delivery, and having first and second ends 284, 286. Inthe embodiment of FIG. 9, the elongated containment portion 282comprises first and second compartments 288, 290 with one compartment288 provided adjacent the first end 284 and one compartment 290 providedadjacent the second end 286. The compartments 288, 290 may havesubstantially the same length, as shown, or may have different lengths.

With each of the embodiments of FIGS. 8 and 9, the compartments may beseparated by a seal, may communicate therebetween, may be substantiallyseparate, or may be otherwise divided with respect to othermulti-compartment embodiments.

One multi-compartment embodiment, shown in FIG. 10, the covering 50comprises first and second compartments 52, 54 situated side-by-side andseparated by a barrier 56. The barrier 56 may be temporary or may besubstantially permanent (remaining for the life of the covering 50). Atemporary barrier may be a sheet or a masking agent. A boundary may beprovided for dividing between two tissue types, for example betweenintervertebral disk and bone, between tendon and bone, between meniscusand bone, or between cartilage and bone. The barrier 56 may be integralwith the covering 50, integral with one of the first and secondcompartments 52, 54, or may be coupled to the covering 50 orcompartments 52, 54.

FIG. 11 illustrates a nested dual-compartment embodiment 60. As shown, asecond compartment 64 is provided within a first compartment 62.Selection of materials for provision in each of the first and secondcompartments may be based on release kinetics from the first compartmentand from the second compartment (provided within the first compartmentand thus also within the material provided in the first compartment). Inone embodiment, smaller particles of a substance are provided within thefirst compartment and the first compartment accordingly comprises atighter mesh while larger particles of a substance are provided withinthe second compartment and the second compartment comprises a loosermesh. Either or both of the first compartment 62 and the secondcompartment 64 may be preloaded. Alternatively, either or both of thefirst compartment 62 and the second compartment 64 may be left empty atmanufacture for loading in the operating room or at the surgical site.In one embodiment, the first compartment may be preloaded and a portprovided to access the second compartment in the operating room or atthe surgical site. In some embodiments, a nesting configuration maycomprise a wrapped configuration.

In some embodiments, at least one but not all of the compartments may beweight-bearing. In other embodiments, all of the compartments may beweight-bearing.

In some embodiments, the covering may be perforated. For example, FIG.12 illustrates a covering 70 comprising as a plurality of compartments72, 73, 74, and 75 separated by perforations 76. The surgeon may selectthe number of compartments desired for placement and cut along aperforation 76 providing that number of compartments. In suchembodiment, every other compartment, for example, may be preloaded orfilled with a substance for delivery. Alternatively, only some of thecompartments may be preloaded, for example, every other compartment maybe preloaded such that alternating compartments may be filled in theoperating room or at the surgical site.

In one embodiment, the covering may comprise a penetrable material at afirst compartment configured for placement adjacent bone and asubstantially impenetrable material at a second compartment configuredfor placement adjacent soft tissue. Alternatively, the material of thecompartments may have substantially identical characteristics. Thecovering then can be positioned in any desirable manner. By way ofexample only, a covering may have a porous surface that is positionedadjacent bone, and a separate or opposite surface that has a generallyimpenetrable surface that is positioned adjacent soft tissue.Alternatively, a covering may have one compartment that comprises aporous material, and a second compartment that comprises a substantiallyimpenetrable material.

In another embodiment, the covering may comprise a continuous tubewherein the tube may be twisted to divide portions of the tube. The tubethus may be divided into a series of implants, each having ends that maybe twisted or heat treated. Any suitable manner of dividing the tubeinto a plurality of compartments may be used. For example, the tube maybe crimped, heat treated, twisted, knotted, stapled, sewn, or otherwisedivided. Any suitable tool may be used for dividing the tube into suchcompartments including, for example, a crimper, a heat tool, or other.

Any other suitable conformation or shape or combination of these alsomay be used.

Attachment Mechanisms

The covering may be configured with structures to permit attachment atthe surgical site, such as to skeletal tissue or to soft tissuestructures, or for attachment to other coverings, or for attachment toadjacent implantable medical devices or products (such as a rod or screwor cross-brace of a pedicle screw fixation system, a hip prosthesis, abone plate, and the like). Generally, the attachment mechanism may beused to retain the covering at the surgical site and any mechanismscapable of doing so may be used. The attachment may be to bone or toadjacent tissues such as muscle, tendon, or ligament. Where the coveringretains a bone graft substance, the covering may be held in a relativelystable position relative to bone (or relative to the surgical site orsurgical defect) to promote bone growth.

The bone or soft tissue to which the covering is attached may beprepared for receiving the attachment mechanism(s). For example, inspinal applications, slots or perforations may be provided in posteriorelements such as transverse processes, spinous processes, or other boneor tissue to receive the attachment mechanism.

Any suitable attachment mechanism may be used, including mechanical,physical, chemical, and biological attachment mechanisms. The attachmentmechanism may be provided at an end of the covering, centrally in or onthe covering, generally in or on the body of the covering, orcombinations of these. U.S. Pat. No. 5,899,939 describes attachmentmechanisms that may be adapted for use with a covering as providedherein, and is herein incorporated by reference. When an attachmentmechanism is used to couple first and second coverings to one another,such attachment or coupling may be done pre-implantation orpost-implantation. In post-implantation embodiments, the coupling may bedone by inserting first and second coverings through an opening into aspace and coupling the coverings within the space. In some embodiments,the covering may be provided with attachment mechanisms to facilitatesuturing or other attachment of the covering in vivo.

FIGS. 13 a-13 c illustrate a covering with a mechanical attachmentmechanism. FIG. 13 a illustrates a covering 200 comprising a compartment202 with a mechanical attachment mechanism 204, such as a hook, asshown, at an end thereof. FIG. 13 b illustrates a covering 200comprising a compartment 202 and ends 206 with a mechanical attachmentmechanism 204 comprising openings 208 at each end 206 of the covering200 and a screw 210 for placement through the opening 208. FIG. 13 cillustrates a covering 200 with a mechanical attachment 204 provided atan end thereof. In various embodiments, the mechanical attachmentmechanism 204 of FIG. 13 c may be a hook, barb, staple, screw, capscrew, nail or tack, bolt, button, tab, flap, hook-and-eye material,loop, rivet, stud, or cam lock (or other conformat fastener), clamp (orcramp), clasp, grommet, pin, retaining ring, rivet, snap, staple, tack,toggle, zipper, other configuration. In some embodiments, hinges,springs, or like mechanisms may be used as attachment mechanisms. Any ofthese fasteners may be made of any suitable material, including metal,ceramic, tissue such as allograft, xenograft, autograft, collagen, anyof the materials listed above in the section entitled Exemplary CoveringMaterials, or combinations of these. In a further embodiment, theattachment mechanism may comprise a press-fit system. In a specificscrew attachment mechanism, attachment may be done via interferencescrew fixation. For example, attachment may be via biodegradableinterference screw fixation. Combinations of these also may be used.

FIGS. 13 d and 13 e illustrate embodiments of physical attachmentmechanisms, e.g., wherein the attachment mechanisms comprise a band-likestructure. FIG. 13 d illustrates a covering 200 comprising a compartment202 and ends 206. Sutures 204 are provided through the ends 206 of thecovering 200. In alternative embodiments, sutures 204 may be providedthrough the compartment 202. FIG. 13 e illustrates a covering 200comprising a compartment 202 and a wrap attachment mechanism 204. Thewrap is provided around the compartment 202 and is generally centrallyplaced. Further physical attachment mechanisms suitable for use, forexample in the embodiment of FIG. 13 e, may comprise wraps, sutures,wires, strings, elastic bands, cables, ropes, chains, plastic wrap,strap, tie, cable tie, or other mechanisms. These mechanisms may becoated, such as with plastic. In some embodiments, a plurality ofmechanisms, such as a multiple parallel wires, may be joined together,for example with a plastic strip coating. Suitable techniques for usingsuch attachment mechanisms may include suturing, stitching, knotting,twisting, cinching, knot tying, and similar techniques. Any of thesephysical fastening materials may be made of any suitable material,including metal, tissue such as allograft, xenograft, autograft,collagen, any of the materials listed above in the section entitledExemplary Covering Materials, or combinations of these.

Chemical attachment mechanisms may comprise, for example, a bioadhesiveor glue, cement, tape, tissue adhesives, or similar mechanism. Chemicalattachment mechanisms may further comprise mechanisms that facilitatecross-linking. In further embodiments, attachment mechanisms such ascrimping, welding, soldering, or brazing may be used. For example,tissue welding may be used (see, for example,http://www.lasertissuewelding.com/laser_mediated_tissue_soldering_andhttp://www.csmgtechinternational.com/presentation.html). Further,attachment may be achieved via friction. FIGS. 13 f and 13 g illustratecoverings with chemical attachment mechanisms. FIG. 13 f illustrates acovering 200 with a compartment 202. An adhesive is placed over asurface of the compartment 202. FIG. 13 g illustrates a covering 200with a compartment 202 and ends 206. An adhesive 204 is placed over theends 206. Suitable adhesives for use with the embodiments of FIGS. 13 fand 13 g include, for example, cyanoacrylates; epoxy-based compounds,dental resin sealants, dental resin cements, glass ionomer cements,polymethyl methacrylate, gelatin-resorcinol-formaldehyde glues,collagen-based glues, inorganic bonding agents such as zinc phosphate,magnesium phosphate or other phosphate-based cements, zinc carboxylate,L-DOPA (3,4-dihydroxy-L-phenylalanine), proteins, carbohydrates,glycoproteins, mucopolysaccharides, other polysaccharides, hydrogels,protein-based binders such as fibrin glues and mussel-derived adhesiveproteins, and any other suitable substance. Adhesives may be selectedfor use based on their bonding time; e.g., in some circumstances, atemporary adhesive may be desirable, e.g., for fixation during thesurgical procedure and for a limited time thereafter, while in othercircumstances a permanent adhesive may be desired. Where the compartment202 is made of a material that is resorbable, the adhesive can beselected that would adhere for about as long as the material is presentin the body. In some embodiments, the covering material may be treatedto form chemical linkages between the covering and adjacent tissue,whether bone or soft tissue.

In some embodiments, biological attachment may be via mechanisms thatpromote tissue ingrowth such as by a porous coating or ahydroxyapatite-tricalcium phosphate (HA/TCP) coating. Generally,hydroxyapatite bonds by biological effects of new tissue formation.Porous ingrowth surfaces, such as titanium alloy materials in a beadedcoating or tantalum porous metal or trabecular metal may be used andfacilitate attachment at least by encouraging bone to grow through theporous implant surface. These mechanisms may be referred to asbiological attachment mechanisms.

Generally, any combination of mechanical, physical, chemical, orbiological attachment mechanisms may be used.

Any of the various attachment mechanisms may be provided as part of thecovering or may be supplied separately. In various embodiments, theattachment mechanisms may be integral to the covering. Alternatively,the attachment mechanisms may be secured to the covering, for example,by stitching, welding, crimping, or other. The attachment mechanisms mayhave any suitable geometric configuration and may optionally includeapertures for receiving other components for coupling in vivo, such asan aperture for receiving a screw. Thus, for example, an attachmentmechanism may be provided configured for receiving an anchor forfixation to bone. Generally, any number of attachment mechanisms may beprovided at any suitable location on the covering.

The attachment mechanisms may be manufactured of the same material asthe portion of the covering to which it is coupled or may bemanufactured of a different material from the portion of the covering towhich it is coupled. The attachment mechanism may be resorbable ornonresorbable. The material of the attachment mechanism may be selectedto allow anchoring the covering to an adjacent covering having acomplementary attachment mechanism or to another structure. In variousembodiments, the attachment mechanism may comprise, allograft, syntheticmaterials, demineralized bone, nondemineralized bone, other material, orcombinations of these. The shape and size of the attachment mechanismmay be selected based on application.

In some embodiments, the covering may be tubular and have threaded endssuch that the ends may be threaded with a reciprocal thread of a furtherdevice or implant. For example, the covering may be used withinterference screws. In some embodiments, the covering may includeextensions or tabs that may be used for wrapping around or suturing tothe surgical site. Alternatively, the covering may be sutured directlyto the surgical site. The ends of the covering may be presealed or maysealed after introduction of contents. Sealing may be done by usingadhesives, heating, solvent treatment, suturing, knotting, or any othermeans.

Spinal Tension Band

A further embodiment is shown in FIGS. 14 a and 14 b. Those figuresillustrate an embodiment comprising a tension band including a coveringfor delivering a substance or material. In accordance with theembodiments shown in FIGS. 14 a and 14 b, the covering may comprise anyof the materials described herein with respect to other embodiments.

Spinal fusion is frequently used as a treatment for various spinaldisorders and is achieved by formation of a bony bridge between adjacentmotion segments eliminating the intervertebral joint. Spinal fusion canbe accomplished within the disc space, anteriorly between adjacentvertebral bodies and/or posteriorly between consecutive processes, e.g.,transverse processes, laminae or other posterior elements of thevertebrae.

One frequently used spinal fusion technique involves removal of theintervertebral disc and insertion of an anterior supporting structure,e.g., bone grafts, bone substitutes, plugs, bone dowels, cages, and thelike, into the intervertebral disc space to prevent collapse of the discspace and promote fusion of the adjacent vertebrae. To ensure propergrowth and fusion between the affected adjacent vertebrae, the posteriorside of the spine may be stabilized by utilizing a rigid metallicimplant, e.g., a plate, rod, wire or strip, which spans the adjacentvertebrae to re-create a load distribution similar to that of the intactspine. These metallic implants are commonly referred to throughout therelevant scientific and medical literature as “tension bands.” U.S. Pat.No. 6,752,831 teaches a biocompatible osteogenic band to stabilize thespine and is herein incorporated by reference in its entirety. As taughttherein, the osteogenic band may be fabricated in whole or in part fromvarious materials, particularly connective type biological materialobtained from human and animal tissues, plants, and insects whichinclude, but are not limited to, e.g., bone, tendon, ligament, silk,collagen, elastin, reticulin, cellulose, alginic acid, chitosan, smallintestine submucosa or combinations thereof. The biological material canbe autogenic, allogenic, transgenic, or xenogenic in origin.

FIG. 14 a illustrates a tension band and covering embodiment 80comprising a tension band or cable 82 and covering 84. As shown, thecovering structure 84 is provided over the tension band or cable 82. Thetension band 82 may comprise an osteogenic material, as described above,or may comprise other suitable material such as synthetic polymer,titanium, stainless steel, or other. The covering structure 84 may befilled with a substance 86, as described herein. In some embodiments,the substance 86 may comprise an osteogenic particulate material. Theoverall dimensions of the tension band and covering delivery system 80can vary widely depending on the distance between affected vertebrae,the site, and the method of affixation. In some embodiments, thedimensions of the tension band and covering delivery system 80 may rangefrom about 1 cm to about 1 meter in length, or from about 3 cm to about8 cm in length, from about 2 mm to about 30 mm in thickness, or fromabout 2 mm to about 10 mm in thickness, and from about 2 mm to about 30mm in width, or from about 2 mm to about 10 mm in width.

The tension cable or band 82 includes first and second end portions 88for coupling with first and second end portions 90 of the coveringstructure 84. Coupling may be achieved in any suitable manner such as byadhesive, by mechanical coupling, or other. The tension cable or band 82further comprises first and second ends 92 affixing or coupling to thevertebrae. The ends 92 may be cut or machined to include threads,grooves, driver head, fasteners, rivets, screws, bolts, pins, etc., toaid in affixing each end portion of the elongated section to thevertebrae. The tension cable or band and covering structure deliverysystem 80, including material, may have dimensions such that, as formed,the system 80 extends between and cover the spinal processes at each endof the system 80. The tension cable or band 82 may be affixed to thespinal processes by any of the mans disclosed in U.S. Pat. No.6,752,831.

FIG. 14 b illustrates a tension band and covering embodiment 100 whereinthe covering 102 includes spreaders 104 such that the covering 102 formsthe tension band. In the embodiment shown in FIG. 14 a, the coveringstructure 100 has sufficient strength to support the spine. Thespreaders 104 substantially prevent the covering 102 from compressingunder load. The covering structure 100 includes first and second ends106, the ends 106 being formed for affixation to the spinal processes.As shown, the ends 106 may be formed into cable structures. First andsecond spreaders 104 may be provided proximate first and second ends ofthe covering structure. The spreaders 104 may have any suitableconfiguration. In some embodiments, the spreaders may comprise discs. Inother embodiments, as shown, the spreaders may comprise rings. Thespreaders 104 may be formed of any biocompatible material including, forexample, a polymer, a metal, or a natural material such as bone.Generally, flexible spreaders may exhibit less strength under loads.

The tension band and covering embodiments shown in FIGS. 14 a and 14 bmay further comprise a substance or material provided in the coveringstructure. The substance or material may be osteogenic, such asdemineralized bone, provided in fiber, liquified, particulate, chunk, ormonolithic form. The substance or material may be an osteogenic proteinor extract in a suitable carrier. Generally, the substance or materialmay be osteoinductive and/or osteoconductive. The substance or materialmay be any material described herein for provision in a covering.

IV. Substance for Delivery by Covering

A substance is provided in the covering, before or during surgery (asdescribed below), for delivery in vivo. Generally, the substance ormaterial may be homogenous or heterogeneous. The substance or materialmay be selected to exhibit certain gradients. For example, the substanceor material may be selected to exhibit a gradient to guide, lure, orattract cells along a pathway. Such gradient may comprise a cellgradient, a cell type gradient (for example transitioning from bonecells to cartilage cells or transitioning from bone cells to tendoncells), a gradient of conductivity, or a gradient of density/porosity.In some embodiments, the substance or material may comprise a sequenceof ingredients.

The covering may be used to deliver a substance comprising any suitablebiocompatible material. In specific embodiments, the covering may beused to deliver surface demineralized bone chips, optionally of apredetermined particle size, demineralized bone fibers, optionallypressed, and/or allograft. For embodiments wherein the substance isbiologic, the substance may be autogenic, allogenic, xenogenic, ortransgenic. Other suitable materials that may be positioned in thecovering include, for example, protein, nucleic acid, carbohydrate,lipids, collagen, allograft bone, autograft bone, cartilage stimulatingsubstances, allograft cartilage, TCP, hydroxyapatite, calcium sulfate,polymer, nanofibrous polymers, growth factors, carriers for growthfactors, growth factor extracts of tissues, demineralized bone matrix,dentine, bone marrow aspirate, bone marrow aspirate combined withvarious osteoinductive or osteoconductive carriers, concentrates oflipid derived or marrow derived adult stem cells, umbilical cord derivedstem cells, adult or embryonic stem cells combined with variousosteoinductive or osteoconductive carriers, transfected cell lines, boneforming cells derived from periosteum, combinations of bone stimulatingand cartilage stimulating materials, committed or partially committedcells from the osteogenic or chondrogenic lineage, or combinations ofany of the above. In accordance with one embodiment, the substance is abone matrix compositions such as described in U.S. patent applicationsSer. No. 12/140,044 and U.S. Patent Publications Nos. 2007/0098756 and2007/0110820 all for Bone Matrix Compositions and Methods, hereinincorporated by reference in their entireties. In some embodiments, thesubstance may be pressed before placement in the covering. A substanceprovided within the covering may be homogenous, or generally a singlesubstance, or may be heterogeneous, or a mixture of substances.

In some embodiments, the substance may be designed to expand in vivo.U.S. Patent Publications No. 2008/0091270 describes an osteoimplant thatexpands in vivo and is herein incorporated by reference in its entirety.Such an embodiment may be used to fill a space and create contact withcongruent surfaces as it expands in vivo, for example for interbodyfusion. Thus, in some embodiments, the delivery system may be used inthe disc space, between implants, or inside a cage.

The covering retains the substance in place by pressure against thecovering. The covering thus may, in some embodiments, maintain particlesof substance in close proximity (for example, where the covering retainsa substance comprising bone particles). Generally, the ratio of coveringmaterial to substance for placement within the covering may be low. Forexample, in some embodiments, the ratio of covering material tosubstance, by weight, may be approximately 1:1,000, 1:100, 1:50, 1:25,1:1, or any suitable ratio that may be higher or lower than these.

In some embodiments the substance delivered by the covering may includeor comprise an additive such as an angiogenesis promoting material or abioactive agent. It will be appreciated that the amount of additive usedmay vary depending upon the type of additive, the specific activity ofthe particular additive preparation employed, and the intended use ofthe composition. The desired amount is readily determinable by oneskilled in the art. Angiogenesis may be an important contributing factorfor the replacement of new bone and cartilage tissues. In certainembodiments, angiogenesis is promoted so that blood vessels are formedat an implant site to allow efficient transport of oxygen and othernutrients and growth factors to the developing bone or cartilage tissue.Thus, angiogenesis promoting factors may be added to the substance toincrease angiogenesis. For example, class 3 semaphorins, e.g., SEMA3,controls vascular morphogenesis by inhibiting integrin function in thevascular system, Serini et al., Nature, (July 2003) 424:391-397,incorporated by reference herein, and may be included in the recoveredhydroxyapatite.

In accordance with some embodiments, the substance may be supplemented,further treated, or chemically modified with one or more bioactiveagents or bioactive compounds. Bioactive agent or bioactive compound, asused herein, refers to a compound or entity that alters, inhibits,activates, or otherwise affects biological or chemical events. Forexample, bioactive agents may include, but are not limited to,osteogenic or chondrogenic proteins or peptides; demineralized bonepowder as described in U.S. Pat. No. 5,073,373; collagen, insolublecollagen derivatives, etc., and soluble solids and/or liquids dissolvedtherein; anti-AIDS substances; anti-cancer substances; antimicrobialsand/or antibiotics such as erythromycin, bacitracin, neomycin,penicillin, polymycin B, tetracyclines, biomycin, chloromycetin, andstreptomycins, cefazolin, ampicillin, azactam, tobramycin, clindamycinand gentamycin, etc.; immunosuppressants; anti-viral substances such assubstances effective against hepatitis; enzyme inhibitors; hormones;neurotoxins; opioids; hypnotics; anti-histamines; lubricants;tranquilizers; anti-convulsants; muscle relaxants and anti-Parkinsonsubstances; anti-spasmodics and muscle contractants including channelblockers; miotics and anti-cholinergics; anti-glaucoma compounds;anti-parasite and/or anti-protozoal compounds; modulators ofcell-extracellular matrix interactions including cell growth inhibitorsand antiadhesion molecules; vasodilating agents; inhibitors of DNA, RNA,or protein synthesis; anti-hypertensives; analgesics; anti-pyretics;steroidal and non-steroidal anti-inflammatory agents; anti-angiogenicfactors; angiogenic factors and polymeric carriers containing suchfactors; anti-secretory factors; anticoagulants and/or antithromboticagents; local anesthetics; ophthalmics; prostaglandins;anti-depressants; anti-psychotic substances; anti-emetics; imagingagents; biocidal/biostatic sugars such as dextran, glucose, etc.; aminoacids; peptides; vitamins; inorganic elements; co-factors for proteinsynthesis; endocrine tissue or tissue fragments; synthesizers; enzymessuch as alkaline phosphatase, collagenase, peptidases, oxidases, etc.;polymer cell scaffolds with parenchymal cells; collagen lattices;antigenic agents; cytoskeletal agents; cartilage fragments; living cellssuch as chondrocytes, bone marrow cells, mesenchymal stem cells; naturalextracts; genetically engineered living cells or otherwise modifiedliving cells; expanded or cultured cells; DNA delivered by plasmid,viral vectors, or other means; tissue transplants; autogenous tissuessuch as blood, serum, soft tissue, bone marrow, etc.; bioadhesives; bonemorphogenic proteins (BMPs); osteoinductive factor (IFO); fibronectin(FN); endothelial cell growth factor (ECGF); vascular endothelial growthfactor (VEGF); cementum attachment extracts (CAE); ketanserin; humangrowth hormone (HGH); animal growth hormones; epidermal growth factor(EGF); interleukins, e.g., interleukin-1 (IL-1), interleukin-2 (IL-2);human alpha thrombin; transforming growth factor (TGF-beta);insulin-like growth factors (IGF-1, IGF-2); parathyroid hormone (PTH);platelet derived growth factors (PDGF); fibroblast growth factors (FGF,BFGF, etc.); periodontal ligament chemotactic factor (PDLGF); enamelmatrix proteins; growth and differentiation factors (GDF); hedgehogfamily of proteins; protein receptor molecules; small peptides derivedfrom growth factors above; bone promoters; cytokines; somatotropin; bonedigesters; antitumor agents; cellular attractants and attachment agents;immuno-suppressants; permeation enhancers, e.g., fatty acid esters suchas laureate, myristate and stearate monoesters of polyethylene glycol,enamine derivatives, alpha-keto aldehydes, etc.; and nucleic acids.

In certain embodiments, the bioactive agent may be a drug. In someembodiments, the bioactive agent may be a growth factor, cytokine,extracellular matrix molecule, or a fragment or derivative thereof, forexample, a protein or peptide sequence such as RGD. A more completelisting of bioactive agents and specific drugs suitable for use in thepresent invention may be found in “Pharmaceutical Substances: Syntheses,Patents, Applications” by Axel Kleemann and Jurgen Engel, Thieme MedicalPublishing, 1999; the “Merck Index: An Encyclopedia of Chemicals, Drugs,and Biologicals”, Edited by Susan Budavari et al., CRC Press, 1996; andthe United States Pharmacopeia-25/National Formulary-20, published bythe United States Pharmcopeial Convention, Inc., Rockville Md., 2001.

In one embodiment of a covering comprising two compartments, a firstgrowth factor may be provided for delivery by the first compartment anda second growth factor may be provided for delivery by the secondcompartment. The first and second growth factors may be provided withother substances. The first and second growth factors may be selected(and placed in respective compartment for positioning in vivo) based ondesired characteristics of the growth factor. For example, an angiogenicgrowth factor may be provided in the first compartment and anosteoinductive growth factor may be provided in the second compartment.

Similarly, the substance delivered by the first compartment and thesubstance delivered by the second compartment may be selected based ondesired characteristics of the compartment according to its placement invivo. Thus, for example, one compartment may have a substance that issubstantially osteoclast stimulating while another compartment may havea substance that is substantially osteoblast stimulating.

In one embodiment, demineralized bone fibers may be provided in thefirst compartment and surface demineralized bone chips may be providedin the second compartment. In this embodiment, the demineralized bonefibers may generally provide osteoinductive characteristics and thesurface demineralized chips may generally provide osteoinductive and/orosteoconductive characteristics. In use, the covering may be laid flaton the transverse process and positioned such that the firstcompartment, holding the demineralized bone fibers, is nearest thevertebral body and the second compartment, holding the surfacedemineralized bone chips, is farther from the vertebral body, or thecompartments may be positioned in any other desired configuration. Inanother embodiment, a covering may comprise first and secondcompartments wherein autograft may be placed in one of the compartmentsprior to placement of the covering in vivo, described more fully below.In other embodiments, three or more compartments may be used, asappropriate for the materials being delivered and the application of thecompartmented implant. More than one substance may be provided in acompartment. For example, surface demineralized bone chips anddemineralized bone fibers may be mixed and provided within a singlecompartment. Such mixture of substances within a single compartment maybe a substantially uniform mix or may be a plurality of substancesplaced in the compartment separately such that they are substantiallyunmixed. When multiple compartments are used, each compartment maycontain one or more substances. Exemplary substances that may beprovided in one or more compartments of the delivery system includecells from the osteogenic precursors, growth factors, angiogenic factorsand other active proteins including bone morphogenic proteins, andcellular scaffolding materials of natural or synthetic origin,antibiotics, and other substances described below.

In some embodiments, other medical devices may be provided within thecovering. For example, one or more electrical stimulator electrodes maybe provided within the covering.

V. Method of Use

The covering delivers the substance or substances in vivo. Such deliverymay be active, passive, by diffusion, or other. Active delivery mayinclude the degradation or decomposition of the covering with theinteraction of body fluids, extracellular matrix molecules, enzymes orcells. It may also include the cleavage of physical and/or chemicalinteractions of substance from covering with the presence of bodyfluids, extracellular matrix molecules, enzymes or cells. Further, itmay comprise formation change of substances (growth factors, proteins,polypeptides) by body fluids, extracellular matrix molecules, enzymes orcells.

The covering is loaded with the substance for placement in vivo. Thecovering may be pre-loaded, thus loaded at manufacture, or may be loadedin the operating room or at the surgical site. Preloading may be donewith any of the substances previously discussed including, for example,DBM, synthetic calcium phosphates, synthetic calcium sulfates, enhancedDBM, collagen, carrier for stem cells, and expanded cells (stem cells ortransgenic cells). Loading in the operating room or at the surgical sitemay be done with any of these materials and further with autograftand/or bone marrow aspirate.

Any suitable method may be used for loading a substance in the coveringin the operating room or at the surgical site. For example, thesubstance may be spooned into the covering, the substance may be placedin the covering using forceps, the substance may be loaded into thecovering using a syringe (with or without a needle), or the substancemay be inserted into the covering in any other suitable manner. FIG. 15illustrates loading the covering 110 with a syringe 112. As shown, insome embodiments, the covering 110 may include a port 114 or otherstructure for receiving the syringe 112 or similar instrument. Specificembodiments for loading at the surgical site include for vertebroplastyor for interbody space filler.

For placement, the substance or substances may be provided in thecovering and the covering placed in vivo. In one embodiment, thecovering is placed in vivo by placing the covering in a catheter ortubular inserter and delivering the covering with the catheter ortubular inserter. The covering, with a substance provided therein, maybe steerable such that it can be used with flexible introducerinstruments for, for example, minimally invasive spinal procedures. Forexample, the osteoimplant may be introduced down a tubular retractor orscope, during XLIF, TLIF, or other procedures. In other embodiments, thecovering (with or without substance loaded) may be placed in a cage, forexample for interbody fusion.

In continuous tube embodiments, the surgeon may divide the tube into thedesired number of compartments, using a crimper, heat tool or other.FIG. 16 illustrates an embodiment of a tubular covering 120 partiallydivided into compartments 122. As shown, the tubular covering 120includes a further portion 124 that may be divided into compartments.After subdivision into compartments 122, one or more compartments 122may be removed from the tube 120 for implantation. Alternatively, in anembodiment wherein the tube is perforated into a plurality ofcompartments, the surgeon may select the number of compartments desiredand cut along the applicable perforation. In some embodiments, some ofthe compartments may be prefilled with a substance for delivery andother compartments may be empty for filling by the surgeon. For example,ever other compartment between perforations may be preloaded or filled.The osteoimplant thus may be customized by filling the emptycompartments with a desired substance.

For example, in some embodiments, a portion of the covering for example,one compartment of a multi-compartment covering, may be filled withautograft. Thus, the covering may be substantially empty prior tosurgery. During surgery, a surgeon may remove autograft from the patientand place the autograft in the substantially empty compartment. Suchplacement may be done in any suitable manner. In one embodiment, thecovering may be provided with a port for receiving an opening of aninjection device and the autograft may be injected into the covering.Alternatively, the autograft may be mixed with allograft, synthetics, orany other desired substances or combination of substances.

Attachment mechanisms provided on the covering may be used to couple thecovering to a site in vivo.

VI. Applications

The covering may be used in any suitable application. In someembodiments, the covering may be used in healing vertebral compressionfractures, interbody fusion, minimally invasive procedures,posterolateral fusion, correction of adult or pediatric scoliosis,treating long bone defects, osteochondral defects, ridge augmentation(dental/craniomaxillofacial, e.g. edentulous patients), beneath traumaplates, tibial plateau defects, filling bone cysts, wound healing,around trauma, contouring (cosmetic/plastic/reconstructive surgery), andothers. The delivery system may be used in a minimally invasiveprocedure via placement through a small incision, via delivery through atube, or other. The size and shape may be designed with restrictions ondelivery conditions.

An exemplary application for using a delivery system as disclosed isfusion of the spine. In clinical use, the covering and deliveredsubstance may be used to bridge the gap between the transverse processesof adjacent or sequential vertebral bodies. The delivery system may beused to bridge two or more spinal motion segments. The coveringsurrounds the substance to be implanted, and contains the substance toprovide a focus for healing activity in the body.

In other applications, the delivery system may be applied to transverseprocesses or spinous processes of vertebrae.

Generally, the delivery system may be applied to a pre-existing defect,to a created channel, or to a modified defect. Thus, for example, achannel may be formed in a bone, or a pre-existing defect may be cut toform a channel, for receipt of the delivery system. The covering may beconfigured to match the channel or defect. In some embodiments, theconfiguration of the covering may be chosen to match the channel. Inother embodiments, the channel may be created, or the defect expanded oraltered, to reflect a configuration of the covering. The covering may beplaced in the defect or channel and, optionally, coupled usingattachment mechanisms.

At the time just prior to when the delivery system is to be placed in adefect site, optional materials, e.g., autograft bone marrow aspirate,autograft bone, preparations of selected autograft cells, autograftcells containing genes encoding bone promoting action, etc., can becombined with the covering and/or with a substance provided within thecovering. The osteoimplant can be implanted at the bone repair site, ifdesired, using any suitable affixation means, e.g., sutures, staples,bioadhesives, screws, pins, rivets, other fasteners and the like or itmay be retained in place by the closing of the soft tissues around it.

U.S. Pat. No. 4,430,760 for Nonstress-bearing Implantable BoneProsthesis, U.S. Pat. No. 6,740,093 for Method and Apparatus forTreating a Vertebral Body, U.S. Pat. No. 4,755,184 for Bone AugmentationImplant, U.S. Pat. No. 5,571,189 for Expandable Fabric Implant forStabilizing the Spinal Motion Segment, U.S. Pat. No. 7,220,282Annulus-Reinforcing Band, U.S. Pat. No. 7,208,015 for Bone RepairDevice, and U.S. Patent Publication No. 2007/0073401 for Method forRepairing Bone disclose various fabrics and structures for containingmaterials for implanting in the body and are herein incorporated byreference in their entireties.

VII. Conclusion

In accordance with various embodiments, a delivery system for delivery asubstance in vivo is provided. The delivery system comprises a coveringand a substance. The covering may be a single or multi-compartmentstructure capable of at least partially retaining a substance providedtherein until the covering is placed at a surgical site. Upon placement,the substance may be released (actively or passively) to the surgicalsite. The covering may participate in, control, or otherwise adjust, therelease of the substance. The delivery system may be used to controlavailability of a substances provided within the delivery system tocells and tissues of a surgical site over time.

Although the invention has been described with reference to preferredembodiments, persons skilled in the art will recognize that changes maybe made in form and detail without departing from the spirit and scopeof the invention.

1-101. (canceled)
 102. A delivery system comprising: a coveringcomprising a first compartment, the covering including a physicalattachment mechanism; a first substance provided within the covering;wherein the covering retains the substance for placement at a surgicalsite and facilitates transfer of the substance or of surroundingmaterials, actively or passively, upon implantation.
 103. The deliverysystem of claim 102, wherein the physical attachment mechanism is awrap.
 104. The delivery system of claim 102, wherein the physicalattachment mechanism is a suture.
 105. The delivery system of claim 102,wherein the physical attachment mechanism is a wire.
 106. The deliverysystem of claim 102, wherein the physical attachment mechanism is astring.
 107. The delivery system of claim 102, wherein the physicalattachment mechanism is an elastic band.
 108. The delivery system ofclaim 102, wherein the physical attachment mechanism is a cable. 109.The delivery system of claim 102, wherein the physical attachmentmechanism is a cable tie.
 110. The delivery system of claim 102, furthercomprising a second compartment.
 111. The delivery system of claim 110,wherein the covering comprises a first end and a second end and whereinthe first and second compartments each extend from the first end to thesecond end.
 112. The delivery system of claim 110, wherein the first andsecond compartments are arranged with the first compartment over thesecond compartment.
 113. The delivery system of claim 110, wherein thecovering comprises a first end and a second end and wherein the firstcompartment is adjacent the first end and the second compartment isadjacent the second end.
 114. The delivery system of claim 110, whereinthe first and second compartments are in communication.
 115. Thedelivery system of claim 110, wherein the first compartment is formed ofa first material and the second compartment is formed of a secondmaterial and wherein the first material and the second material are notthe same.
 116. The delivery system of claim 102, wherein the coveringcomprises a mesh.
 117. The delivery system of claim 102, wherein thecovering comprises a functional material.
 118. The delivery system ofclaim 102, wherein the covering comprises a structural material. 119.The delivery system of claim 102, wherein the covering further comprisesa reinforcing material.
 120. The delivery system of claim 102, whereinthe covering is flexible.
 121. The delivery system of claim 102, whereinthe substance is particulated and wherein the covering retains particlesof the substance in spatial proximity to one another.
 123. The deliverysystem of claim 102, wherein the covering is porous.
 124. The deliverysystem of claim 102, wherein the covering comprises an activelyreleasing material and is configured to release such material duringdegradation of the covering.
 125. The delivery system of claim 102,wherein the delivery system is tubular.
 126. The delivery system ofclaim 125, wherein the tubular covering is configured for subdivisioninto smaller tubular compartments in an operating room.
 127. Thedelivery system of claim 102, wherein the covering comprises anelongated containment portion and first and second ends and wherein theattachment mechanism is provided at at least one of the first and secondends.
 128. The delivery system of claim 127, wherein the coveringfurther comprises a seal at at least one of the first and second ends.129. The delivery system of claim 102, wherein the attachment mechanismis integral to the covering.
 130. The delivery system of claim 102,wherein the attachment mechanism is provided separately from thecovering and is attached to the covering for use.
 131. The deliverysystem of claim 102, wherein the attachment mechanism attaches thedelivery system to a tissue structure.
 132. The delivery system of claim102, wherein the first substance is bone.
 133. The delivery system ofclaim 102, further comprising a tension band.
 134. The delivery systemof claim 102, wherein the attachment mechanism cooperates with anattachment mechanism of a second covering. 135-198. (canceled)